Syphilis rates rise among gays; will increases in HIV follow?

Experts stress the need for public health departments, the gay community and physicians to work together to raise sexual safety issues.

By Susan J. Landers, amednews staff. Nov. 25, 2002.

Washington -- A new report showing that cases of syphilis are increasing among gay and bisexual men underscored alarms raised in recent years by several city and state health departments that risky sexual behaviors are on the upswing and could result in a new round of AIDS infections.

The Centers for Disease Control and Prevention found that, after a decade-long decline, the number of reported cases of syphilis increased from 5,979 cases in 2000 to 6,103 cases in 2001. Although the numbers were small, the fact that they were concentrated among gay and bisexual men raised the specter of AIDS.

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"Syphilis outbreaks among gay and bisexual men, while a major concern in and of themselves, also signal the potential for a resurgence in HIV transmission," said Ronald O. Valdiserri, MD, MPH, deputy director of CDC's National Center for HIV, STD and TB Prevention.

Although there are no data specific to syphilis among gay and bisexual men, the fact that the increase coincided with outbreaks of syphilis among that group in several American cities led to the conclusion drawn by the agency.

Since at least some of those men are also infected with the AIDS virus, public health officials fear that the transmission of the much more deadly disease could increase.

"The data suggest that, although efforts to reduce syphilis among women and non-Hispanic blacks appears effective and should continue, efforts to prevent and treat syphilis among MSM [men who have sex with men] need to be improved," said the report published in the Nov. 1 Morbidity and Mortality Weekly Report.

The increase is also a setback for CDC's effort to eliminate syphilis from the United States. The agency established that goal in 1998 with aggressive public health campaigns that targeted those most affected by the disease, namely blacks and people living in the Southeast.

While progress was made in those targeted areas, gay and bisexual men seem to have been missed.

The CDC is already working to correct that situation, having dispatched teams of workers to aid local health departments in getting the word out to the gay community that individuals at risk for AIDS need to know their status and, if they do test positive, they must protect partners from infections.

Seattle is one city that has been trying to convey that message to the gay and bisexual population. Although there have been only 50 or 60 cases of early syphilis reported recently in the city, that group tends to have multiple, anonymous sex partners indicating that the spread of syphilis and also AIDS may be broader.

"Many of the prevention messages have been aimed at trying to help HIV-negative men to stay that way," said Connie Celum, MD, MPH, associate professor of medicine at the University of Washington School of Medicine, Seattle.

But a different message is needed for men already infected, she noted. That message needs to stress that sexually transmitted diseases such as syphilis are not just a trivial nuisance. The men need to realize that they are putting others at risk and themselves at greater risk of developing resistant strains of HIV or contracting other STDs that could foster the progression of their own illness, said Dr. Celum.

Risky sexual behaviors are on the upswing.

Public health officials are convinced that the increase in risky behavior is linked to greatly improved therapy and survival rates for people with AIDS, said H. Hunter Handsfield, MD, director of the STD Control Program at the Seattle and King County Public Health Dept.

There is probably more to it than the effectiveness of new treatments that have turned AIDS into a chronic disease, Dr. Handsfield speculated. "The knee-jerk, simplistic response is that gay men are complacent because AIDS is curable and they don't have to worry about it any more," he said.

But the fact that communities in which many gay men live are no longer populated by numbers of gaunt figures with the purple lesions of Kaposi's sarcoma can't help but promote a behavior change, said Dr. Handsfield. "With appropriate therapy, it's not an obviously sick community," he said. "And, guess what, healthy-feeling people are more sexual than people who feel sick."

"People who aren't being confronted in their daily environment with sick and dying friends and colleagues are probably responding differently than they were before," said Dr. Handsfield.

Drs. Celum and Handsfield would welcome help from the gay community in halting the spread of high-risk behaviors by promoting the continued use of condoms as well as fostering a sense of responsibility for the health of a sexual partner.

"I think there needs to be more community alarm from the male gay and bisexual community to say that this is serious," said Dr. Celum.

"You need some combination of public health department, health care providers in general and the gay community," she said. "That consortium so far has been an abject failure."

Physicians need to be more watchful for STDs among their gay and bisexual patients, said Dr. Celum. Some cases were missed because physicians thought the rash of early syphilis was caused by a reaction to antiviral medications for AIDS. "We've seen cases where someone has been seen by their [doctor] two or three times before the [doctor] realized they should be thinking more broadly," said Dr. Celum.

"I think the average doc makes the tacit assumption that his or her HIV-infected patients must be behaving safely because, of course, that is the commonsense thing to do," said Dr. Handsfield.

Acknowledging that raising sexual safety issues and insisting on periodic tests for STDs and HIV tests for patients at risk can be time-consuming and difficult, the fact remains that "They've got to do it," he stressed.

Physicians also shouldn't be afraid to moralize a little bit, said Dr. Handsfield. "They don't need to put it in highly moral, emotionally charged terms," he said. But if patients have HIV they have the responsibility to tell their partners, he added.

Dr. Handsfield parcels out the responsibility to three sectors: "The gay community hasn't been responsible in working toward behavior change; public health needs to do more in terms of working with both gay men and others at risk for HIV; and the private medical sector needs to step up to the plate and be part of the solution as well," he said.

ADDITIONAL INFORMATION:

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Article, "Primary and Secondary Syphilis -- United States, 2000-2001," Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Nov. 1 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5143a4.htm)